to - Chiropractor La Quinta CA

HASHIMOTO CHIROPRACTIC INC.
COLEMAN & HASHIMOTO CHIROPRACTIC & ACUPUNCTURE INC.
PATIENT INFORMATION
Name ________________________________________________ Date __________________
Address _______________________________ City _____________ State _____ Zip _______
Home Phone (______)_________________ Work Phone (______)_________________
Cell Phone (______)_________________ Cell Phone Carrier: _______________________
Email _____________________________ Social Security No. ________________________
Date of Birth ______________ Age _______ Sex:
Height _________Weight _________ Preferred Language: _______________
Race:
American Indian or Alaska Native
Asian
Black or African American
Caucasian
Native Hawaiian or Pacific Islander
Other
Ethnicity:
Hispanic or Lat
Occupation _____________________________ Employer _____________________________
Spouse’s Name _____________________________ Employer __________________________
Person Responsible for Payment ________________________ SSN ________________
How did
IN CASE OF EMERGENCY, CONTACT
Name _____________________________________ Relationship ________________________
Home Phone (______)_________________ Work Phone (______)_________________
ACCIDENT INFORMATION
PATIENT CONDITION
Reason for Visit ________________________________________________________________
When did your symptoms appear? ______________________________________
Rate the severity of your pain on a scale from 0 (no pain) to 10 (severe pain) __________
-
-
What percentage of time do you experience this proble
Does it interfere with your:
47875 Caleo Bay Dr A104, La Quinta, CA 92253 P: 760-777-8377 F: 760-777-9377
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Family members with similar problems:_____________________________________________
What treatment have you already received for your condition?
HEALTH HISTORY
Please mark “Yes” or “No” to indicate if you have had any of the following:
AIDS/HIV
High Blood Press.
Other ____________
Yes
No
Yes
No
Cancer
Diabetes
Heart Disease
Yes
Yes
Yes
No
No
No
High Cholesterol
Osteoporosis
Pacemaker
Yes
Yes
Yes
No
No
No
Stroke
Yes
No
Smoking Status:
Female Only
Former Smoker
Pregnant?
MEDICATIONS/SUPPLEMENTS
Yes
Never Smoked
No
DOSAGE &
FREQUENCY
REASON
HOW LONG?
Injuries/Surgeries _______________________________________________________________
Drug Allergies & Allergies
Substance or
Medication Name
Reaction
Onset Date
47875 Caleo Bay Dr A104, La Quinta, CA 92253 P: 760-777-8377 F: 760-777-9377
Additional
Comments
Hashimoto Chiropractic Inc.
Coleman & Hashimoto Chiropractic & Acupuncture Inc.
Dr. Nora Coleman, DC, LAc
Dr. Naota Hashimoto, DC
INFORMED CONSENT
TO CHIROPRACTIC & ACUPUNCTURE CARE
I hereby consent and request the performance of chiropractic and acupuncture procedures, including adjustments, examination tests, diagnostic x-rays, physiotherapy, acupuncture, laser, massage, Chinese
herbal medicine and nutritional supplements for the purpose of treatment, on me or for whom I am legally responsible, by the clinical staff at Hashimoto Chiropractic Inc.
I have been informed that chiropractic and acupuncture are generally safe methods of treatment, but that,
as with any health care procedure, there may be certain complications or side effects. Side effects include soreness, bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Unusual risks include, but are not limited to, fractures, disc injuries, strokes, dislocations, sprains, organ puncture, and burns. The herbs and nutritional supplements (which are from plant,
animal and mineral sources) are traditionally considered safe, although possible side effects of the taking
the herbs including abdominal discomfort may occur. The clinic uses sterile disposable needles and
maintains a clean and safe environment. I will notify a staff member who is caring for me if I am or become pregnant.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications
of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment
which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment. I have been told about the risks and benefits of chiropractic and acupuncture and other procedures,
and have had an opportunity to ask questions. I intend this consent form to cover the entire course of
treatment for my present condition and for any future condition(s) for which I seek treatment.
_________________________________________
Printed Name of Patient
______________________
Date
_________________________________________
Signature of Patient, Parent, or Guardian
We have many success stories in our office and often patients wish to share these stories in an effort
to help others. Your picture, written testimonial or video will only be shared with your permission
and will only be available when YOU PROVIDE it to us. This is a standard publicity release in accordance with the Federal Trade Commission (FTC).
I hereby grant you, Hashimoto Chiropractic Inc. all rights with this my irrevocable explicit approval
to use my likeness, voice, etc., as captured or edited, recorded and rendered in various audio, visual, and
written medium, to be used in commercial, instructional, and promotional activities as Hashimoto
Chiropractic Inc. sees fit. Hashimoto Chiropractic Inc. shall own 100% rights, title and interest in resulting product.
Please sign here stating that you understand the above: _________________________
47875 Caleo Bay Dr Ste A104, La Quinta, CA 92253 P: 760-777-8377 F: 760-777-9377
Health Information Privacy Practices Act Notice (HIPPA)
Effective Date: September 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Hashimoto Chiropractic Inc. at 760-777-8377
OUR OBLIGATIONS:
We are required by law to:

Maintain the privacy of protected health information

Give you this notice of our legal duties and privacy practices regarding health information
about you

Follow the terms of our notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
The following describes the ways we may use and disclose health information that identifies you (“Health
Information”). Except for the purposes described below, we will use and disclose Health Information only
with your written permission. You may revoke such permission at any time by writing to our practice Privacy
Officer.
For Treatment. We may use and disclose Health Information for your treatment and to provide you with
treatment-related health care services. For example, we may disclose Health Information to doctors, nurses,
technicians, or other personnel, including people outside our office, who are involved in your medical care
and need the information to provide you with medical care.
For Payment. We may use and disclose Health Information so that we or others may bill and receive
payment from you, an insurance company or a third party for the treatment and services you received. For
example, we may give your health plan information about you so that they will pay for your treatment.
For Health Care Operations. We may use and disclose Health Information for health care operations
purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care
and to operate and manage our office. For example, we may use and disclose information to make sure the
obstetrical or gynecological care you receive is of the highest quality. We also may share information with
other entities that have a relationship with you (for example, your health plan) for their health care operation
activities.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use
and disclose Health Information to contact you to remind you that you have an appointment with us. We
also may use and disclose Health Information to tell you about treatment alternatives or health-related
benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health
Information with a person who is involved in your medical care or payment for your care, such as your family
or a close friend. We also may notify your family about your location or general condition or disclose such
information to an entity assisting in a disaster relief effort.
Research. Under certain circumstances, we may use and disclose Health Information for research. For
example, a research project may involve comparing the health of patients who received one treatment to
those who received another, for the same condition. Before we use or disclose Health Information for
research, the project will go through a special approval process. Even without special approval, we may
permit researchers to look at records to help them identify patients who may be included in their research
project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.
SPECIAL SITUATIONS:
As Required by Law. We will disclose Health Information when required to do so by international, federal,
state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary
to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Business Associates. We may disclose Health Information to our business associates that perform functions
on our behalf or provide us with services if the information is necessary for such functions or services. For
example, we may use another company to perform billing services on our behalf. All of our business
associates are obligated to protect the privacy of your information and are not allowed to use or disclose any
information other than as specified in our contract.
Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to
organizations that handle organ procurement or other entities engaged in procurement, banking or
transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release Health Information as
required by military command authorities. We also may release Health Information to the appropriate
foreign military authority if you are a member of a foreign military.
Workers’ Compensation. We may release Health Information for workers’ compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose Health Information for public health activities. These activities
generally include disclosures to prevent or control disease, injury or disability; report births and deaths;
report child abuse or neglect; report reactions to medications or problems with products; notify people of
recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition; and the appropriate government authority if we believe a
patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.
Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits, investigations, inspections, and
licensure. These activities are necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide
legally required notices of unauthorized access to or disclosure of your health information.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in
response to a court or administrative order. We also may disclose Health Information in response to a
subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if
efforts have been made to tell you about the request or to obtain an order protecting the information
requested.
Law Enforcement. We may release Health Information if asked by a law enforcement official if the
information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited
information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim
of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement;
(4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our
premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity,
description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or
medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause
of death. We also may release Health Information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may release Health Information to authorized federal
officials for intelligence, counter-intelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose Health Information to authorized federal
officials so they may provide protection to the President, other authorized persons or foreign heads of state
or to conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may release Health Information to the correctional institution or law
enforcement official. This release would be if necessary: (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of
the correctional institution.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT
Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member
of your family, a relative, a close friend or any other person you identify, your Protected Health Information
that directly relates to that person’s involvement in your health care. If you are unable to agree or object to
such a disclosure, we may disclose such information as necessary if we determine that it is in your best
interest based on our professional judgment.
Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek
your Protected Health Information to coordinate your care, or notify family and friends of your location or
condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure
whenever we practically can do so.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be made only with your written
authorization:
1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply
to us will be made only with your written authorization. If you do give us an authorization, you may revoke it
at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected
Health Information under the authorization. But disclosure that we made in reliance on your authorization
before you revoked it will not be affected by the revocation.
YOUR RIGHTS: You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to
make decisions about your care or payment for your care. This includes medical and billing records, other
than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in
writing, to Hashimoto Chiropractic Inc. We have up to 30 days to make your Protected Health Information
available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies
associated with your request. We may not charge you a fee if you need the information for a claim for
benefits under the Social Security Act or any other state of federal needs-based benefit program. We may
deny your request in certain limited circumstances. If we do deny your request, you have the right to have
the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your
request, and we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is
maintained in an electronic format (known as an electronic medical record or an electronic health record),
you have the right to request that an electronic copy of your record be given to you or transmitted to
another individual or entity. We will make every effort to provide access to your Protected Health
Information in the form or format you request, if it is readily producible in such form or format. If the
Protected Health Information is not readily producible in the form or format you request your record will be
provided in either our standard electronic format or if you do not want this form or format, a readable hard
copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the
electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured
Protected Health Information.
Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to
amend the information. You have the right to request an amendment for as long as the information is kept
by or for our office. To request an amendment, you must make your request, in writing, to 47875 Caleo Bay
Dr, Ste A104, La Quinta, CA 92253
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of
Health Information for purposes other than treatment, payment and health care operations or for which you
provided written authorization. To request an accounting of disclosures, you must make your request, in
writing, to 47875 Caleo Bay Dr, Ste A104, La Quinta, CA 92253.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Health
Information we use or disclose for treatment, payment, or health care operations. You also have the right to
request a limit on the Health Information we disclose to someone involved in your care or the payment for
your care, like a family member or friend. For example, you could ask that we not share information about a
particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in
writing, to 47875 Caleo Bay Dr, Ste A104, La Quinta, CA 92253. We are not required to agree to your request
unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health
plan for payment or health care operation purposes and such information you wish to restrict pertains solely
to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply
with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill
your health plan) in full for a specific item or service, you have the right to ask that your Protected Health
Information with respect to that item or service not be disclosed to a health plan for purposes of payment or
health care operations, and we will honor that request.
Right to Request Confidential Communications. You have the right to request that we communicate with
you about medical matters in a certain way or at a certain location. For example, you can ask that we only
contact you by mail or at work. To request confidential communications, you must make your request, in
writing, to 47875 Caleo Bay Dr, Ste A104, La Quinta, CA 92253. Your request must specify how or where you
wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to
give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you
are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site,
www.desertpainrelief.com. To obtain a paper copy of this notice, call 760-777-8377.
CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to
Health Information we already have as well as any information we receive in the future. We will post a copy
of our current notice at our office. The notice will contain the effective date on the first page, in the top
right-hand corner.
COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our office
or with the Secretary of the Department of Health and Human Services. To file a complaint with our office,
contact the doctors. All complaints must be made in writing. You will not be penalized for filing a complaint.
By signing this Agreement, you are only acknowledging that you have received or been given the opportunity
to receive a copy of our Notice of Privacy Practices.
Signature: ________________________________ Date_____________________________
Print Name: ________________________________
Hashimoto Chiropractic Inc. & Coleman & Hashimoto Chiropractic & Acupuncture Inc.
FINANCIAL & PRIVACY AGREEMENT
Welcome to Hashimoto Chiropractic & Acupuncture. We want your experience here to be as pleasant as possible.
To acquaint you with our payment arrangements please review the following and sign in acknowledgement.
1. No insurance: Unless other arrangements are made with the billing manager, payment is expected at the time
services are rendered. We accept personal checks, cash, Visa, or MasterCard.
2. Group Health Insurance: We will bill your insurance claims for you. However, we ask that you remember the
following: insurance is an agreement between yourself and the insurance company. Any balance beyond what the
insurance covers is your responsibility. We will contact your insurance company to verify eligibility and coverage, but
we are not responsible for any misinformation that the insurance company may give us. Most insurance plans
require you make a co-payment, co-insurance and/or deductible. It is your responsibility to pay these amounts at the
time service is rendered unless a specific agreement is made with the billing manager. We are willing to carry the
portion owed by your insurance company for 60 days. If your insurance company does not pay their expected
amount within 60 days then the charges in full will be collected from the patient. Any unpaid balances beyond 60
days are subject to a 5% service charge per month.
3. Work Comp: Work related injuries are managed in conjunction with your employer. Employers carry insurance for
this type of injury and they must authorize care and give us the billing information. Most employers will authorize
care however, they have medical control for the first thirty days, meaning they can choose who treats you, unless you
have a “designated doctor” form on file with the employer previous to your injury. You will not be responsible for
your charges unless you elect to treat with us against your employer’s wishes.
4. Personal Injury: We will bill your auto insurance med pay. If you have group insurance we will also bill that for you
unless your med pay coverage covers the entire amount of your medical claim. We do not accept group insurance
benefits as full payment when there is a third party. If you retain a Personal Injury attorney (approved by this office),
we will accept a lien. An approved attorney will fall under the following guidelines: you must formally retain the
attorney, attorney must respond to monthly status calls, you and the attorney agree to sign a lien insuring we will be
paid from the proceeds of the settlement. Ultimately, you are responsible for the total amount of the bill, the terms
are explained in the lien agreement that you and your attorney are required to sign. We reserve the right to cancel
the lien agreement at any time. In any case, once you are released from care we will wait only six months for
payment. We reserve the right to charge a 5% service charge per month on the unpaid balance until settlement.
5. Medicare: I understand that my Medicare insurance policy covers 80% for spinal manipulation only. It does NOT
cover examinations, radiographs (x-rays), or modalities. Therefore, I agree to be personally responsible for all noncovered services. I understand that this office must perform an initial evaluation in order to render manipulation
under the Medicare agreement. I also understand that I am responsible for a yearly deductible and a co-insurance
amount for covered services at the time those services are rendered.
6. Missed Appointments/Cancellations: There is a $25.00 cancellation charge for missed or cancelled appointments
with less than 24 hours notice. You will be billed directly for any cancellation charges.
ACKNOWLEDGMENT AND UNDERSTANDING: I understand and agree that health and accident insurance policies are an
arrangement between an insurance carrier and myself. Furthermore I understand that this office will prepare any
necessary reports and forms to assist me in making collection from the insurance company and that any amount
authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse coissued remittances for the conveyances of credit to my account. However, I clearly understand and agree that all services
rendered me are charged directly to me and that I am personally responsible for payment.
I also understand that if I suspend or terminate care and treatment, any fees for professional services rendered to me will
be immediately due and payable.
In the event that my account is forwarded to a collection agency, a charge of 35% of the ENTIRE balance will be applied
for proper processing and settlement of the account. The collection agency also charges daily interest. There is a $35
non-sufficient funds fee for returned checks in addition to what the bank charges for this office for a non-sufficient funds
returned check. We reserve the right to charge a 5% service charge per month on any unpaid balances beyond 60 days.
Please notify us in advance if there are any circumstances that prevent you from meeting these financial arrangements.
I understand and agree to the above financial form.
__________________________ __________________________ _______________
Patient Signature
Printed Name
Date
47875 Caleo Bay Dr A104, La Quinta, CA 92253 P: 760-777-8377 F: 760-777-9377